|Procedure||ADA Code||Fee*||With Aetna**||You Save||%|
|Routine 6 Month Check-up||ADA Code: D0120||Usual Fee*: $73.50||With Aetna**: $24.75||You Save: $48.75||Saving Percentage: 66%|
|Full Mouth X-Rays||ADA Code: D0210||Usual Fee*: $171.50||With Aetna**: $66.50||You Save: $105.00||Saving Percentage: 61%|
|Adult Teeth Cleaning||ADA Code: D1110||Usual Fee*: $125.00||With Aetna**: $53.00||You Save: $72.00||Saving Percentage: 58%|
|Child Teeth Cleaning||ADA Code: D1120||Usual Fee*: $91.00||With Aetna**: $37.50||You Save: $53.50||Saving Percentage: 59%|
|Perio Scaling and Root Planing (Per Quadrant)||ADA Code: D4341||Usual Fee*: $289.75||With Aetna**: $137.75||You Save: $152.00||Saving Percentage: 52%|
|1 Surface Silver Filling for Primary or Permanent Tooth||ADA Code: D2140||Usual Fee*: $198.75||With Aetna**: Call||You Save: Call||Saving Percentage: Call|
|1 Surface White Filling for U or L Front Tooth||ADA Code: D2330||Usual Fee*: $222.75||With Aetna**: $83.50||You Save: $139.25||Saving Percentage: 63%|
|Root Canal Treatment – Front Tooth||ADA Code: D3310||Usual Fee*: $1,060.75||With Aetna**: $392.25||You Save: $668.50||Saving Percentage: 63%|
|Root Canal Treatment – Bicuspid||ADA Code: D3320||Usual Fee*: $1,169.25||With Aetna**: $463.75||You Save: $705.50||Saving Percentage: 60%|
|Root Canal Treatment – Molar||ADA Code: D3330||Usual Fee*: $1,490.50||With Aetna**: $652.50||You Save: $838.00||Saving Percentage: 56%|
|Full Upper Denture||ADA Code: D5110||Usual Fee*: $1,932.50||With Aetna**: $879.00||You Save: $1,053.50||Saving Percentage: 55%|
|Single Tooth Extraction||ADA Code: D7140||Usual Fee*: $267.00||With Aetna**: $74.25||You Save: $193.25||Saving Percentage: 72%|
|Wisdom Tooth Extraction (Impacted Tooth, Soft Tissue)||ADA Code: D7220||Usual Fee*: $443.00||With Aetna**: Call||You Save: Call||Saving Percentage: Call|
Discounted fees are listed for visits to a participating general dentist. Actual costs and savings may vary by provider, service and geographic location. The discounted fee represents the average cost of the negotiated fees for Tampa, Dallas, Chicago and New York City. Individual dentist fee schedules may differ. In order to determine the specific rates for a dental provider, you should contact the dental provider directly.
The Aetna Vision℠ discount program helps you save on eyeglasses, sunglasses, contact lenses and solutions, LASIK, and more. Best of all, it’s automatically included with your Aetna – Vital Savings by Aetna® Dental, so you don’t pay any extra to get the program.
We’ve contracted with EyeMed Vision Care to bring you a broad network of eye care providers including Pearle Vision®, LensCrafters®, JCPenney®Optical, Target Optical® and participating Sears Optical® locations. In addition, thousands of independent eye care providers are available. Most participating locations have doctors of optometry practicing right on the premises or at a nearby location. Even if you don’t have eye exam coverage through your health benefits plan, you can still get a great rate on eye exams for eyeglasses or contact lenses.
Savings vary. For exact costs, check with the provider before your visit.